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HomeMy WebLinkAboutBUSINESS PLAN 12/27/1999 Per ; l' = it Operil.te to Hazardous Materials/Hazardous Waste Unified Permit , '. ,CONDITIONS, OF ,PERM.IT ON REVERSE SIDE ~' .~ . - . ., , .~ ." . " . . . I' . ~' \: :, . .-,' ;- ., This oermlt Is Issued for the following: , it Hazardous Materials Plan o Underground Storage of Hazardous Materials o Risk Management Program o Hazardous Waste On-Site Treabne.1t .. . ., .t ," Permit ID #:: 015-000-001732 STOCKDALE , AUTO ELECTRI "i;'. LOCATION: 3621 STOCKDALE HWY .' . '. ~ " . .~"... .' '." #." Issued by: + "':::: .;.-< .';~ ":' . ;'.'., . :" -:í . . .-.. . ~ . , ;.. . .. ." . , ;.- Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SERVICES· 1715 ,Chester Ave.t 3rd Floor Bakersfieldt CA 93301 Voice (661) 326-3979 FAX (661) 326-0576 Approved by: <~ RaI Huey, : 'OfficeofEv' Services June 30, 2003 Issue Date . i . Exþitation Date: · '''' ,., h , , ,. . k' '. Per...Ït ,¡-.. to Operil.te Hazardous Materials/Hazardous W aste Unified Permit CONDITIONS OF PERMIT ON REVERSE SIDE This permit is issued for the following: :::tI~~ardous Materials Plan "" ~[øround Storage of Hazardous Materials . agement Program Waste 3621 PERMIT ID# 01S-Q21.Q01732 STOCKDALE AUTO ELECTRI LOCATION Issued by: STOCKDA Bakersfield Fire Department OFFICE OF ENVIRONMENTAL SER VICES 1715 Chester Ave., 3rd Floor Bakersfield, CA 93301 Voice (805) 326-3979 FAX (805) 326-0576 *~ ph Huey, ffice of ental Servi es Approved by: Expiration Date: June 30, 2000 . f~ " I¡-.: oJL L,JÞ<S ~ ........ ......... -,.... .... ~ ...... .-. -~-- .. --.-- Business Name: /' 4IIi I 0/ I FACIUTY DIAGRAM .:;.~&..I<.() ~ At./ro E:<..Ed"- ¢ ~<3- - SITE DIAGRAM Business ACcress: sc" z. ( S'TõC¡.(1)4c...€ ~y ror Office Use Only FirST !n Sterion: Area Meo ;; ~t !nscec~on $te~on: NORïH 0- .¡l$\JC'lC-"tìA Wb(...,- <:"f.{-, £..~ 0Ut)ArJc£ <J...,1"he- . (:..fl.é ~~()Q.)..Jr - c::;-rz:,c. K. DA:L-~ +*...v r¿ \ C é) ) ( r f""oslC-.:e. ~ - ~ee-z..c=- w£>.s,-(G . Olt..- I,.. . ç,~-u:.-% cÇ4 s~ ''". -......, \ : V J1)~!) .--."' WII.?,¡¡: 0('- Î4.IJK (A.ß.ðJVf)¡Vc.-o) Af.AR.X f\-\.GrJ 'IS gTOC-KI)M..(; WEs\ SHr:>PP',J&- GG-rJ rC-tL. -; - "-... ;;- - -~ It - STOCKDALE AUTO ELECTRIC & SMOG SiteID: 215-000-001732 Manager : BusPhone: (805) 837-1482 Location: 3621 STOCKDALE HWY Map : 123 CommHaz : Low City BAKERSFIELD Grid: 02B FacUnits: 1 AOV: CommCode: BAKERSFIELD STATION 03 SIC Code: EPA Numb: DunnBrad: Emergency Contact / Title Emergency Contact / Title JUAN LARA JR. / OWNER JOE LARA / CO-OWNER Business Phone: (805) 837-1482x Business Phone: (805) 837-1482x 24-Hour Phone : (805) 831-1156x 24-Hour Phone : (805) 831-1156x Pager Phone : ( ) - x Pager Phone : ( ) - x Hazmat Hazards: Fire DelHlth - L~ð--- (g(¡;~ t~7 - /'l'Ý.¡- Contact : :J 0'"'(... Phone: MailAddr: 3621 STOCKDALE HWY State: CA City : BAKERSFIELD /, Zip : 93309 /~ Owner JUAN LARA ' ...,:/ ;/'=:,:') Phone: (805) 831-1156x Address : 4714 ENCORE ST // State: CA City BAKERSFIELD ./ C) " \GCO Zip 93313 : , '. _ú 1_ \.) f" " : / Period : to ' ::~ :.;,,\:';L\~:;TotaIASTs : = Gal Preparer: TotalUSTs: = Gal Certif'd: RSs: No .' - Emergency Directives: One Unified List ì All Materials at Site ì p= Hazmat Inventory p== MCP+DailyMax Order Hazmat Common Name... SpecHaz EPA Hazards DailyMax MCP WASTE OIL F DH L 55.00 GAL Low I, ~. . ;./ Le; "r~ hereby e~rtiiy tlh~~ ~ hSlVS ypa or print narnø) reviewed the attached hazardous materials manage- ment plan ~Of (!\Jams of 9wJ~ - $100 ~&"o~~ ift &l!~fiî(QJ wiftfn any corrsdi@i1s oonsiiftlBft® ® oompls~e and roIlY®©\( men- agement plan for n¡y facility. ' L -1- 12/21/1999 ~ '. e e F STOCKDALE AUTO ELECTRIC & SMOG p= Inventory Item 0001 F= COMMON NAME / CHEMI CAL NAME WASTE OIL SiteID: 215-000-001732 ì Facility Unit: Fixed Containers at Site ì Days On Site 365 Location within this Facility Unit OUTSIDE N/W CORNER OF SHOP. Map: Grid: CAS # 221 STATE - TYPE Liquid Waste PRESSURE ---- TEMPERATURE Ambient Ambient CONTAINER TYPE DRUM/BARREL-METALLIC Largest Container GAL AMOUNTS AT THIS LOCATION Daily Maximum 55.00 GAL Daily Average 55.00 GAL %Wt. RS CAS # 100.00 Waste Oil, Petroleum Based No 0 HAZARDOUS COMPONENTS TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP No No No No/ CUries F DH / / / Low HAZARD ASSESSMENTS -2- 12/21/1999 .' .,. - e F STOCKDALE AUTO ELECTRIC & SMOG I p= Notif./Evacuation/Medical Agency Notification SiteID: 215-000-001732 9 Fast Format 9 Overall Site 9 03/08/1996 TELEPHONE AVAILABLE INSIDE OFFICE AND SHOP ALARM SYSTEM MAINTAINED BY PROTECTION ONE (800) GET-HELP Employee Notif./Evacuation 03/08/1996 VERBAL NOTIFICATION IS SUFFICIENT TO ISSUE EVAUCATION WARNING TO SHOP AND FOSTER'S FREEZE PATRONS. Public Notif./Evacuation 03/08/1996 FOSTER'S FREEZE ADJACENT TO THE EAST OF PROPERTY. Emergency Medical Plan 03/08/1996 MERCY HOSPITAL : (CLOSEST) FIRST AID KIT IN BACK ROOM - --- - --- -'.,.~ -- -3- 12/21/1999 .. -. e e F STOCKDALE AUTO ELECTRIC & SMOG I p= Mitigation/Prevent/Abatemt Release Prevention SiteID: 215-000-001732 ì Fast Format ì Overall Site ì 03/08/1996 "GREASESWEEP" ABSORBANT AVAILABLE FOR SMALL SPILLS Release Containment 03/08/1996 METAL CONTAINER USED TO KEEP USED ABSORBANT IN. Clean Up 03/08/1996 KERN OIL RECYCLING PICKS UP WASTE OIL (805) 792-2,472 Other Resource Activation - - - ---~ .____ _,,-_ o~__ -'-~ ~--=--..",-'-""" <--'--"-- ~-,-,-- ~ -4- 12/21/1999 ,; '. e e f STOCKDALE AUTO ELECTRIC & SMOG I p= Site Emergency Factors I Special Hazards. Utility Shut-Offs SiteID: 215-000-001732 ì Fast Format, ì Overall Site ì I 03/08/1996 NATURAL GAS/PROPANE: N/A ELECTRICAL: INSIDE WALL OF BACK ROOM WATER: UNDER SIDEWALK CENTER OF NORTH END OF PROPERTY. SPECIAL: NONE Fire Protec./Avail. Water 03/08/1996 TWO 2-A 10:BC EXTINGUISHERS INSIDE SHOP AREA. FIRE HYDRANT ON NORTH SIDE OF STOCKDALE HWY. Building Occupancy Level ~ _ -_ _-r...,-_____---=--"___ - .____ ~~---~~~~-- ~- -5- 12/21/1999 .¡. . ~ ....... e e í STOCKDALE AUTO ELECTRIC & SMOG ëëëëëëëëëëëëëëëëëëëëëë SiteID: 215-000-001732 ¡ íëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Fast Format j íë Training ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë Overall Site j íëë Employee Training ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë 03/08/1996 ¡ o 0 o NUMBER OF EMPLOYEES: 2 o o o o MATERIAL SAFETY DATA SHEETS ON FILE: N/A WASTE OIL ONLY o o o o BRIEF SUMMARY OF TRAINING PROGRAM: KERN OIL FILTER RECYCLING PROVIDES BASIC 0 o INSTURCTION ON HANDLING AND STORAGE OF WASTE OIL. 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëë Page 2 ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëj o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëë Held for Future U se ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë j o 0 o o åëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf íëëëëë Held for Future Use ëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëë¡ o 0 o o äëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëëf ~- --- -- -~-. --,,- -..,..... - ----~~- --.------,..-~ e e ,Â- ~. ~ ... ..r, '.., S~ U Auú &~ &SmIUf 3621 Stockdale Hwy. Bakersfield, CA 93309 (805) 837 -1482 ~ · e ; Jl.tcv IL CiA u,J &- 3,blq 7--6¿kJ....!J¿ -,--. --- q "3 "3Ò,,! " e /:-r <, ,~~ BAKERe=IELD CITY FIRE'DEARTMENT HAZARDOUS MATERIALS DIVISION 1715 'CHESTER AV£: BAKERSFIELD, CA. 93301 HAZARDOUS MATERIALS MANAGEMENT PLAN '~J- V:.Q>¿ GT 0- (\ 1;.')- S(1 INSTRUCTIONS: 1. io avoid further action, return this form within '30 days of receipt. 2. ¡YPE/PRINT ANSWERS IN ENGUSH. 3. Answer the auestions below tor the business as a whole. .:1. 6e brief end concise as possible. SECTION 1: BUSINESS IDENTIFICATION DATA 3USiNESS NAME: S"'R:X.1.(tI)A(...E AeJíV ELc-c..(t?.Ic. ¢ ~,,","o6 LCC,;TICN: 3bG.-l S'1õC.Kò4<..c:. ~(,I :v1AIlING ACC,RESS: q,Þnv...2 '-"I~V' \...,..; It, ~-" -:-- -¡D· q ~10'1 ::J, HONE'. '2'37 - (4g'2... ...,¡~ì:::._L~\. ~L!N & 5Rß,2Sïí{t=t NUMBE~: SIC C80::: ?R¡:vîARY ,-\C~;V1T'(: ,:::;WNER: JVA-N LMA, ~R. \¡i.~,j~:\JG ,.:.,= :~=~~: 4 "1 (4 L -NCo,U3 c.;t 153/3 SEC710N 2: =MERG=NCY NOT¡FiC;"j¡ON: CONTACT ;iTl :: 3US. PHONE 24 HR. ?HONE ~~ LÁI'(A ~~ ì. (;)vJ~- 1?"37 -- ( 4 <ð'L ~31 - If Ç6 '" Jö6-- ¿ftLA L Cù -o..J.AJ GR... v( '2>'13>- «s7Q7 "-... ..u<::I.A.~l.;::¡u.~.LU ~ U"e .J..Jept. .ardous Materials Division e HAZARDOUS M~TERIAlS MANAGEMENT PLAN ¡ ~... \ ... v '. ð SECTION 3: TRAINING: NUMBER OF EMPLOYEES: L. MATERIAL SAFETY DATA SHEETS ON FIL~: tJ(A ~TG- c.xL CJro.J1..Iv' BRIEF SUMMARY OF TRAINING PROGRAM: ¡::;. C~ 0 ( <- h(...T8t...' ~c::.(.f-'G- PWtJ,I)CS BoAS Ie. I f\J S "l1ù.JC.. 't1o~ 0,..)- ~DUNG i ~~ ~' W'Â<; æ: <::xt....-. SECTION 4: EXEMPTION REQUEST: : Cé:~T¡FY UNDER P~NALTY OF P~RJURY THA f MY 8USiNESS IS EXEMPT FROM THE ~E?ORTING RE';:'UIREMENTS OF C:-iAPTER ó.95 OF THE "CALlFORNIA HE.A.LiH & 3AF::TY CODE" ~CR THE ~OLLCWING REASONS: WE DO NOT HANDL:: :-i.A.ZAROCUS MATê~IALS. 'HE GO HANDLE HAZ.~.ROCUS MA TER!A,LS, 3UT THE QUANTITiES A ï NO ~¡ME=:<C==J THE MINIMUM ¡~E~CRnNG ~UANTrnES. ,-'"'\"-:"::::::; rc:::c:(":::v rc:\ >::"'""Nì Vlll_'\. \VI _'-"14 t 1\'-.-.v\....,1 , SECTION 5: CERTIFIC~TION: I, JUA:...J L-MA ~Q.. Cé:RTIFY THAT THE ABOVE INFOR- MAilON IS ACCURATE. ! UNDERSTAND THAT THIS INFORMATION WILL BE USED TO FULFiLL MY FiRM'S CBUGA nONS UNDER ¡HE "C.;UFORNIA HE.Â.LTH AND SAF::TY ceDE" ON H.A.ZAROOUS MATERIALS (D¡V. 20 CHAPTER ó.95 SEC. 25500 ET Al.) AND THAT INACCURATE INFORMATIONCCNSTlTUTES PERJURY. ~ ()0Y\1GL nTlE 7-!c11c¡~ DATE. ---------- - -- - ---- . . , -.. r;;: ~,';";. e Hazardous Materials Division e HAZARDOUS. MATERIALS MANAGEMENT PLAN . .' þ .- FacHity Unit Name: 5"'i"DcJ<DtI.(.~ .Åt>T'O 'E-t-Ec:: t "'S."'"'UI (;. SECTION 6: NOTIFICATION AND EV ACUATION PROCEDURES: A. AGENCY NOTIFICATION PROCEDURES: -¡-c-u:::-P¡.(orJt;; ,A.V~tc...A.rtc...E. 1,J~¡JJ'é- oFF, cE '! SI4ol' A CM.M .s YSTt:::-:1V MAIN 7A..,..¡éO ;~~ r(ZDTéC(fU,..! c>f'oJE ('600") c:;.~ 7 - H. ¡; c...P 3,=MPLOYE= NOTIFICATION AND E·'/ACUAilON: vCJ?.ßA.L- NOTlF'CA-:r-(~ (~ $u{--r=,c..¿,'N( To IS<ÇúE í3vA<-vA:n,~ r..AJ'('Y'¿NIN(:;- .....-?.l ;:::u"P.to, r-_.ç~~, « cn-'--' I U ....~ ~ t-'Q, ''--'L'" l<..<=e;'è6' (~.\'é(òrJ s . .-. ,--" ?U8L:C ="/ACJAï¡CN: ~TC-'ê.. ("':> ç~cz.c AJßU:v"r -ró -«1-(E E. ö-r-- f'Rùf'C-r-tK/ ...., ~. =~¡1E~G~:-'JC,( V1EO¡CAL ~~.':,N: M.Cf?...~ý ~~P''TA'-- (c.:<..VSZ:-S:<1) Ç.R.t:;í AiD K,q'"" ,I\,) ßLI<:K <200"'-1. ... . ::""Ilk e Bakersfield Fire Dept. e Hazardous Materials Division ~~ """_... ~ì " HAZARDO'U5 MATERIALS MANAGEMENT PLAN .;., ~ . t "' SECTtON 7: MITIGATION, PREVENTION AND ABATEMENT PLAN: A. RELEASE PREVENTION STEPS: " G ~.:c.~~sw~f> 'I ACS~;-I, A;JAILA()~ ~ ~"'"'t Â( c.. St'¡ '-t-5 3. RELEASE-CONTAINMENT AND/OR MINIMIZATION: I'A<:-TA-l- (ot\.ÍTL:\,rJC-t2.- <JSc-r.> "TC Kéêf? usc-o Aß.sae;3A,.J'ï IN '-' . CL=.~,N-UP PROCEQURES: t<~ DIL !?éCY;<:"'I..J(: 'YtCKS uP WA-STE OIL ('ðo)) 7'72-'2.47'-. SeCTION 8: UTILITY SHUT-OFFS (LCCAïION OF SHUT-()FFS AT YOUR FAC¡UTY): \1 ..\ .,..u 1;"\ ,\ I ,~ '. ç: I" R 0 D ^ N E· ,1M1 ~M_ ..::;,-....... I 'I I~t . æ/A =~=':~R!C/;~: iN",' 0 6 WA t...(... 01= ßAC.I( (2ooM '.\1 ' ,,= ~ . ÙND[:.J2.. ~ I \')~.At. \~ Cc-AJT~R... <>Ç' IV c~ ôC <?I2oPC~T<,J , r-,I,-,C 5;: '~I= :~,L: Loe:,3CX: '(r::S/NO \F 'i~2, ~·~C ; ¡ION: SECTION 9: PRIV ATE FIRE PROTECTION/W A TEx A V AILABILlTY: : A. ?RIV A TE FiRE PROTECTION: A O~ ßc... ~-I.rJ('··,,,J.J.-~"- ,,,v$0I><:- ~t' p¡z;sð. ......¡-ï..,)() 2. - I, '-- =<.J ,,--- ~ B. WATER AVAILABIUTY (FiRE HYDRANT): A c.!2-o s:> 01\/ I\J $ I () E 0 ç;: $-ro <:: K.)l.kLE' .L.tt-vl,.l t··' . , . BAKE~~¡[ELD CITY FIRE DEPARTMENT H~DOUS MATERIALS INVE.RY Page_of_ .. 8u~i~ess Name Sïõüa)~ /xUØ ~'\~ Address 3b2-1 $TOe1.( () Ät.€ #t..J i 1 CHEMICAL DESCRIPTION , 1) INVENTORY STATUS: New¡Øt Addition ( ) Revision ( ) Deletion ( ) Check if chemical is a NON TRADE SECRET fsR' TRADE SECRET '( J 2) Common Name: WAS--rG Olt- 3) DOT # (optioilal) i Chemical Name: AHM ( ) CAS # i 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire 4;9! Re8CÛW{ ) Sudden Releue of Pressure ( I Immectlate HuIth (Acute) ( ] Delay.ld Health (Chronic) e : 5) WASTE CLASSIFICATION 2"l..-{ (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid ( J Uquicl ~ Gas I J Pure I J Mixture I J Weste ~ FIacIioec:tiw ( J CHECK AU. 1>iAr__r 7) AMOUNT AND TIME AT FACIUTY ÇS- UNITS OF MEASURE 8) STORAGE CODES G Muimum Daily Amount: Ibs(]gal~ ft3 ( J a) Container: Averag4t Daily Amount: ç"5' curies ( ) b) Pressure: ( Annual Amount: SS- e) Temperature: 4- Largest Size 'Container: ~S- # Days On Site '3bS"' Circle Which Months: All Year. J. F, M, A. M. J. J. A. S. O. N. D 9) MIXTURE: Ust COMPONENT CAS # %WT AHM the three most hazardous 1} lAJAS<íE PL......,...(2.dL.C~ ( oë:> ( ) chemical components or any AHM components 2) [ ) 3} [ J :1 10) Location ct;-rs,O€, NW CJÙ.JR... oÇ' ~ I i CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New ( I Addmon( J Re~s~n( J Deletion I J Check if chemical is a NON TRADE SECRET ( J TRADE SECRET ( ] 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # ¡ 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ 1 Reactive [ J Sudden Release of Pressure [ ] Immediate Health (Acute) [ ] Delayed Health (Chronic) ( ] 5) WASTE ClASSIFICATlON (3-digit code from DHS Form 8022) USE CODe 6) PHYSICAL STATE Solid [ J !..íquid [ ¡ Gas [ ] Pure [ J Mixture [ ] Waste ( I Radioactive ( ] '.;h'ECJ< ALL THAT A.PPl '" 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: Ibs ( ] gal [ ] ft3 ( J a) Container: Average Daily Amount: curies ( ] b) Pressure: Annual Amount: c} Temperature: Largest Size Container: # Days On Site Circle Which Months: AU Year. J. F. M, A, M, J. J, A, S. 0, N, D I ¡ 9) MIXTURE: Ust COMPONENT CAS # %WT AHM the three most hazardous 1) [ ) chemical components or any AHM components 2) [ ] ., 3) ( ] 1 0) Location certify under penalty of law, that I have personally eJCamlned and am familiar wlm me mfomeoon suomltted on this ancI all att8ctlecl aocuments. I oel/eve me submitted information is true. accurate. and complete. ~LJp.,J Lþf<-f>....J(2.. ~NC.t2.... : PRINT Name & Title of Authorized Company Representative s~ ?./~'/7£ Date utW'JiIIylø;Dl";'"'.........,.,,~.. BAKERSF~D CITY FIRE DEPA.MENT HAZAR~OUS MATERIALS INVENTORY , Page_of-i~ : usiness Name Address CHEMICAL DESCRIPTION 1) INVENTORY STATUS: N_ I I Addition I I Revision I I Deletion I I Check if chemical is a NON TRADE SECRET [ ] TRADE SECRET [ ] 2) Common Neme: 3) DOT # (optional) Chemical Name: AHM [] CAS # 4) PHYSICAL & HEALTH PHYSICAl HEALTH HAZARD CATEGORIES Fire II Reactive I ] Sudden Releese of Pressure I I Immediete Health (Acute) ( J ~ HøIIh (Chronic) [ J 5) WASTE CLASSIACATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid ( I Liquid [ I Gas [ J Pure ( ] Mixtunt [ ] Waste ( ] Radioactive [ J, CHEClCAU. THAT N'A.Y 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: Ibs [ I gal [ ] 13 [ J a) Container: Average Daily Amount: curies [ I b) Pressure: Annual Amount: c) Temperature: largest Size Container: # Days On Site Circle Which Months: All Year, J. F, M, A. M, J, J, A. S, 0, N, D 9) MIXTURE: List COMPONENT CAS # %WT AHM the three most hazardous 1) [ J chemical components or any AHM components 2) [ I 3) [ I 1 0) Location CHEMICAL DESCRIPTION 1) INVENTORY STATUS: New [ I Addition [ ] Revision [ ] Deletion [ J Check if chemical is a NON TRADE SECRET [ I TRADE SECRET [ I 2) Common Name: 3) DOT # (optional) Chemical Name: AHM [ ] CAS # 4) PHYSICAL & HEALTH PHYSICAL HEALTH HAZARD CATEGORIES Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] Immediate Health (Acute) [ I Delayed Health (Chronic) [ ] 5) WASTE CLASSIFICATION (3-digit code from DHS Form 8022) USE CODE 6) PHYSICAL STATE Solid [ ] liquid [ ] Gas [ ] Pure [ ] Mixture [ I Weste [ I Radioactive [ I ŒfCl<AU.. ~Ar APPlY 7) AMOUNT AND TIME AT FACIUTY UNITS OF MEASURE 8) STORAGE CODES Maximum Daily Amount: lbs [ J gal [ ] ft3 [ ] a) Container: Average Daily Amount: curies [ ] b) Pressure: Annual Amount: c) Temperature: largest Size Container: # Days On Site Circle Which Months: All Year, J. F, M. A, M, J, J, A. S, 0, N, D 9) MIXTURE: List COMPONENT CAS # %WT AHM the three most hazardous 1) [ I chemical components or any AHM components 2) [ I 3) [ J 10) location i:8ff1ty under penalty of law, that I have personally examined and am famíliar WIth the Infomat1on submitted on this anet allattllcnect etocuments. I Delleve the ubmitted information is true, accurate, anet complete. , 'HJNT Name &- Title of Authorized Company Representative Signature Dam